title: An Epidemiologic Investigation of Potential Risk Factors for Nodding Syndrome in Kitgum District, Uganda.
abstract: Nodding Syndrome (NS), an unexplained illness characterized by spells of head bobbing, has been reported in Sudan and Tanzania, perhaps as early as 1962. Hypothesized causes include sorghum consumption, measles, and onchocerciasis infection. In 2009, a couple thousand cases were reportedly in Northern Uganda.
  
  
  
  In December 2009, we identified cases in Kitgum District. The case definition included persons who were previously developmentally normal who had nodding. Cases, further defined as 5- to 15-years-old with an additional neurological deficit, were matched to village controls to assess risk factors and test biological specimens. Logistic regression models were used to evaluate associations.
  
  
  
  Surveillance identified 224 cases; most (95%) were 5-15-years-old (range = 2-27). Cases were reported in Uganda since 1997. The overall prevalence was 12 cases per 1,000 (range by parish = 0·6-46). The case-control investigation (n = 49 case/village control pairs) showed no association between NS and previously reported measles; sorghum was consumed by most subjects. Positive onchocerciasis serology [age-adjusted odds ratio (AOR1) = 14·4 (2·7, 78·3)], exposure to munitions [AOR1 = 13·9 (1·4, 135·3)], and consumption of crushed roots [AOR1 = 5·4 (1·3, 22·1)] were more likely in cases. Vitamin B6 deficiency was present in the majority of cases (84%) and controls (75%).
  
  
  
  NS appears to be increasing in Uganda since 2000 with 2009 parish prevalence as high as 46 cases per 1,000 5- to 15-year old children. Our results found no supporting evidence for many proposed NS risk factors, revealed association with onchocerciasis, which for the first time was examined with serologic testing, and raised nutritional deficiencies and toxic exposures as possible etiologies.
authors.affiliation: Division of Nutrition, Physical Activity and Obesity, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Foltz
authors.forename: Issa
authors.initials: I
authors.lastname: Makumbi
authors.forename: James J
authors.initials: JJ
authors.lastname: Sejvar
authors.forename: Mugagga
authors.initials: M
authors.lastname: Malimbo
authors.forename: Richard
authors.initials: R
authors.lastname: Ndyomugyenyi
authors.forename: Anne Deborah
authors.initials: AD
authors.lastname: Atai-Omoruto
authors.forename: Lorraine N
authors.initials: LN
authors.lastname: Alexander
authors.forename: Betty
authors.initials: B
authors.lastname: Abang
authors.forename: Paul
authors.initials: P
authors.lastname: Melstrom
authors.forename: Angelina M
authors.initials: AM
authors.lastname: Kakooza
authors.forename: Dennis
authors.initials: D
authors.lastname: Olara
authors.forename: Robert G
authors.initials: RG
authors.lastname: Downing
authors.forename: Thomas B
authors.initials: TB
authors.lastname: Nutman
authors.forename: Scott F
authors.initials: SF
authors.lastname: Dowell
authors.forename: D K W
authors.initials: DK
authors.lastname: Lwamafa
mesh_terms: D000293:Adolescent; D016022:Case-Control Studies; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D008297:Male; D064128:Nodding Syndrome / Q000453:epidemiology*; D012307:Risk Factors; D014454:Uganda / Q000453:epidemiology